Basic Information
| Provider Information | |||||||||
| NPI: | 1225442049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAREY-BULLARD | ||||||||
| FirstName: | SUSAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 PORTABELLA TRL | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488584006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897722967 | ||||||||
| FaxNumber: | 9897729454 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 PORTABELLA TRL | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488584006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897722967 | ||||||||
| FaxNumber: | 9897729454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502002865 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 235490 | 05 | MI | MEDICAID |